Provider Demographics
NPI:1245229020
Name:OLSON, RANDALL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:J
Last Name:OLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 W WATER ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-1776
Mailing Address - Country:US
Mailing Address - Phone:563-382-4302
Mailing Address - Fax:
Practice Address - Street 1:511 W WATER ST
Practice Address - Street 2:SUITE C
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-1776
Practice Address - Country:US
Practice Address - Phone:563-382-4302
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA76521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice